What is the treatment for mild hepatic steatosis?

Treatment of Mild Hepatic Steatosis

The primary treatment for mild hepatic steatosis is lifestyle modification with a goal of weight loss through dietary changes and increased physical activity, targeting at least 5% weight loss to improve steatosis. 1, 2

Lifestyle Modifications

Weight Loss Goals

• For patients with overweight/obesity:
  • ≥5% weight reduction to reduce steatosis
  • 7-10% weight reduction to improve inflammation

  • 10% weight reduction to improve fibrosis 1, 2

• For patients with normal weight:
  • 3-5% weight reduction is recommended 1

Dietary Recommendations

1. Mediterranean diet pattern is strongly recommended 1, 2

   • High in vegetables, fruits, whole grains, olive oil
   • Moderate fish and white meat consumption
   • Limited red and processed meat

2. Specific dietary restrictions:

   • Minimize processed meat and ultra-processed foods
   • Avoid sugar-sweetened beverages
   • Replace saturated fats with polyunsaturated and monounsaturated fatty acids
   • Limit excess fructose consumption 1, 2

3. Coffee consumption has been associated with improvements in liver damage in observational studies 1

Physical Activity

• At least 150 minutes/week of moderate-intensity OR 75 minutes/week of vigorous-intensity physical activity 1, 2
• Exercise should be tailored to individual preferences and abilities 1
• Exercise alone can reduce hepatic steatosis even without significant weight loss 2, 3

Monitoring and Follow-up

• Reevaluation after 3-6 months of lifestyle intervention 2
• Monitor using:
  • Liver enzymes (ALT, AST)
  • Imaging techniques (ultrasound, CAP, or MRI-PDFF) 2
• Changes in non-invasive markers (e.g., MRI-PDFF relative reduction by >30%, ALT reduction by >17 U/L) have been associated with resolution of steatohepatitis 1

Special Considerations

Alcohol Consumption

• Complete abstinence from alcohol is recommended for patients with advanced fibrosis or cirrhosis
• Significant limitation of alcohol consumption is recommended for other patients 2

For Patients with Cirrhosis

• With sarcopenia or decompensated cirrhosis: high-protein diet and late-evening snack
• With compensated cirrhosis and obesity: moderate weight reduction plus high-protein intake and physical activity 1

Pharmacological Treatment

For mild hepatic steatosis without significant fibrosis, pharmacological therapy is generally not recommended as first-line treatment. However, if lifestyle modifications fail:

• Resmetirom may be considered for adults with non-cirrhotic steatohepatitis and significant hepatic fibrosis (stage ≥2) if locally approved 1, 2

• GLP-1 receptor agonists (such as semaglutide and liraglutide) are not specifically recommended for steatohepatitis but may provide indirect hepatic benefits through weight loss 1, 2

• Vitamin E, pioglitazone, and nutraceuticals are not recommended due to insufficient evidence of effectiveness and potential long-term risks 1, 2

Common Pitfalls to Avoid

• Focusing only on liver enzymes can miss significant liver disease 2
• Ignoring cardiovascular risk, which is the main driver of morbidity and mortality before development of cirrhosis 2
• Rapid weight loss can potentially worsen liver inflammation; gradual, sustained weight loss is preferred 2, 4
• Inadequate follow-up and poor adherence to lifestyle changes 2

Multidisciplinary Approach

Given the multidirectional connections between MASLD and cardiometabolic comorbidities, a multidisciplinary approach is recommended to ensure all components are appropriately targeted to improve both liver-related and extrahepatic outcomes 1, 5